Strategic Modeling of the PediatricNurse Practitioner WorkforceGreggory J Schell MSEa Mariel S Lavieri PhDa Xiang Li BSEa Alejandro Toriello PhDb Kristy K Martyn RN PhDcGary L Freed MDd

abstract OBJECTIVE To assess the current pediatric nurse practitioner (PNP) workforce and to investigatethe impact of potential policy changes to address forecasted shortages

METHODSWe modeled the admission of students into nursing bachelorrsquos programs and followedthem through advanced clinical programs Prediction models were combined with optimaldecision-making to determine best-case scenario admission levels We computed 2 measures(1) the absolute shortage and (2) the expected number of years until the PNP workforce willbe able to fully satisfy PNP demand (ie self-sufficiency)

RESULTS There is a forecasted shortage of PNPs in the workforce over the next 13 years Under thebest-case scenario it would take at least 13 years for the workforce to fully satisfy demand Ouranalysis of potential policy changes revealed that increasing the specialization rate for PNPs by 4would decrease the number of years required until there are enough PNPs from 13 years to 5 yearsIncreasing the certification examination passing rate to 96 from the current average of 869would lead to self-sufficiency in 11 years In addition increasing the annual growth rate of masterrsquosprograms to 36 from the current maximum of 107 would result in self-sufficiency in 5 years

CONCLUSIONS Current forecasts of demand for PNPs indicate that the current workforce will beincapable of satisfying the growing demand Policy changes can result in a reduction in theexpected shortage and potentially improve access to care for pediatric patients

WHATrsquoS KNOWN ON THIS SUBJECT The numberof nurse practitioner graduates in the UnitedStates has nearly doubled over the past 2decades However the number of pediatric nursepractitioner (PNP) graduates has remainedrelatively flat although the demand for PNPs isexpected to increase

WHAT THIS STUDY ADDS This study estimatesthe best-case shortage of PNPs over the next25 years We propose possible policyinterventions to address key areas of the PNPworkforce system and we compute their impacton the forecasted PNP shortage

aDepartment of Industrial and Operations Engineering and dChild Health Evaluation and Research Unit Universityof Michigan Ann Arbor Michigan bSchool of Industrial and Systems Engineering Georgia Institute of TechnologyAtlanta Georgia and cSchool of Nursing Emory University Atlanta Georgia

Mr Schell drafted the initial manuscript assisted in the collection of data and analyzedand interpreted the results Drs Lavieri and Toriello conceptualized and designed the study andreviewed and revised the manuscript Mr Li assisted in the collection of data and analyzed andinterpreted the results Drs Martyn and Freed conceptualized and designed the study assisted inthe collection of data and reviewed and revised the manuscript and all authors approved the finalmanuscript as submitted and agree to be accountable for all aspects of the work

wwwpediatricsorgcgidoi101542peds2014-0967

DOI 101542peds2014-0967

Accepted for publication Nov 5 2014

Address correspondence to Mariel S Lavieri PhD Department of Industrial and OperationsEngineering University of Michigan 1205 Beal Ave Ann Arbor MI 48109 E-mail lavieriumichedu

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE The authors have indicated they have no financial relationships relevant tothis article to disclose

FUNDING All phases of this study were supported by a University of Michigan MCubed grant

POTENTIAL CONFLICT OF INTEREST The authors have indicated they have no potential conflicts ofinterest to disclose

ARTICLE PEDIATRICS Volume 135 number 2 February 2015 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

Analysis of the aggregate nursepractitioner (NP) workforce revealsa near doubling in the number of NPgraduates in the United States since1996 However this supply increasehas not been equitable across the NPspecialties Family nurse practitioners(FNPs) have experienced the largestgrowth in graduates whereas thenumber of new pediatric nursepractitioner (PNP) graduates hasremained relatively flat1

Furthermore the majority of statescurrently have fewer than 25 PNPsper 100 000 children2 This supply ofPNPs will be unable to meet thedemonstrated increasing demand inboth pediatric primary care practicesand subspecialty clinics3 Inparticular the competition betweenprimary and subspecialty pediatricpractices for the limited supply ofPNPs will likely lead to difficulties inaccessing pediatric subspecialtyservices4 A failure to address thesepediatric health workforce concernswill affect pediatric care and will havelong-term consequences on the healthof the entire population56

It has been hypothesized that theincreasing demand for pediatricservices is due in part to increasedsurvival rates and disease burden ofchildren with chronic illnessesincluding obesity diabetes andasthma7 In addition the increasedprevalence of delayed childbearing isleading to low birth weights andcomplications necessitatingadditional pediatric care8 There hasalso been a significant shift in the

proportion of child health visits fromfamily physicians to pediatricians9

PNPs are increasingly providingindependent care to patients withcomplex diseases and workingcollaboratively with attendingphysicians to manage the increaseddemand for pediatric service1011

Given the increasing demand as wellas the key role of PNPs in providingpediatric care we focused onmodeling the workforce system ofPNPs

Modeling the aggregate nursingworkforce or even the aggregate NPworkforce is insufficient for detectingand addressing the challenges facedspecifically in the PNP supply Rathera systematic framework is needed formodeling the workforce challenges ofPNPs to identify beneficialinterventions for improving access tocare This need for modelingworkforce challenges is mirrored inthe Affordable Care Actrsquosauthorization of a National HealthCare Workforce commission anda National Center for WorkforceAnalysis whose priorities includeidentifying methods needed todevelop accurate predictions of futureworkforce needs12 The necessity forimproved workforce planning modelsand educational changes has alsobeen echoed by George Thibaultpresident of the Josiah MacyFoundation13 and by recent studiesincluding those by Iglehart14 andDall15 Our work aims to complementthe existing literature on the nursingworkforce (eg Auerbach16and

Buerhaus et al17) by includingoptimal decision-making withforecasting models of PNP supply anddemand

To address the worsening scarcity ofPNPs and the expanding demand fortheir professional services wedeveloped a novel framework foranalyzing the PNP workforce in theUnited States and present the impactof a variety of policy options that willaffect the pipeline of registerednurses (RNs) and nursing schoolstudents who enter PNP trainingprograms Using the proposedframework we provide policysuggestions for addressing thedisparity between supply anddemand of PNPs Our work offersinsight into the benefit of policyinterventions and contributes towardimproved workforce planning models

METHODS

We modeled the admission ofstudents into nursing bachelorrsquosprograms and followed them throughadvanced clinical programs in PNPeducation (masterrsquos programs) orentrance into the RN workforce (seeFig 1) Baccalaureate students werecategorized as traditional part-timestudents traditional full-timestudents part-time RN-to-baccalaureate students and full-timeRN-to-baccalaureate students with 54 2 or 1 years required to completetheir degree upon admissionrespectively Upon graduation fromthe nursing baccalaureate program

FIGURE 1Attrition is defined as the annual percentage of a stagersquos population leaving the system (eg the annual percentage of nursing baccalaureate studentsdropping out of the program)

PEDIATRICS Volume 135 number 2 February 2015 299 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

the graduated student either enteredthe RN workforce after passing theRN examination or enrolled in an NPmasterrsquos program Our modeling alsoallowed employed RNs to exit theworkforce and enroll in an NPmasterrsquos program while ensuringa minimum number of RNs remain inthe workforce Of those who enrolledin an NP masterrsquos program in a givenyear the PNP specialization ratedefined the percentage of enrolled NPmasterrsquos students who selected PNPas their specialty and hence becamePNP masterrsquos students PNP masterrsquosstudents were categorized as eitherfull-time or part-time students Full-time masterrsquos students completedtheir degree in 2 years whereas part-time students completed their degreein 3 to 5 years Upon graduation fromthe PNP masterrsquos program thegraduated student entered theworkforce after passing the nationalPNP certification examinationFurthermore at each education andprofessional category (eg third-yearbachelorrsquos student) enrolled studentsand employed RNs and PNPs wereallowed to exit the education orworkforce system (ie we modeledboth education and workforceattrition) Attrition rates for eachcategory were computed as thepercentage of studentsnurses whowould leave the educationworkforcesystem each year

We used data and categories fromEnrollment and Graduations inBaccalaureate and GraduatePrograms in Nursing by the AmericanAssociation of Colleges in Nursing(AACN)18 to compute initialpopulation sizes attrition rates andgraduation rates for baccalaureateand masterrsquos nursing students Fromthe AACN we also computed the rateof students entering nursing masterrsquosprograms who specialize in NP andthe rate of NP students specializing inPNP The attrition rate of PNPs fromthe workforce was computed byusing recertification rates between2011 and 2013 from the PediatricNursing Certification Board19

Attrition rate of RNs from theworkforce were calculated from theNational Sample Survey of RegisteredNurses20 RN and PNP examinationpassing rates were calculated fromthe National Council of State Boardsof Nursing21 and the PediatricNursing Certification Board22

respectively Data for the initialworkforce levels of RNs and PNPscame from the AACN NursingShortage Fact Sheet23 and theNational Association of PediatricNurse Practitioners 2013 StateMap24 respectively Payroll costs forRNs FNPs and PNPs came from theUS Department of Laborrsquos Bureau ofLabor Statistics25 Annual demandgrowth for PNPs in the workforce(5) was computed as the averageannual change in the number of PNPsin the United States from 2009 to20132426

We used linear programming todetermine optimal admissiondecisions every year of the planninghorizon (25 years) that would lead tosatisfying the demand for PNPs27

The approach used to model the PNPworkforce and to derive optimaldecisions is described in Lavieri andPuterman28 The optimal admissiondecisions for a particular year are thenumber of students admitted tonursing baccalaureate programs thenumber of bachelorrsquos studentsadmitted to NP masterrsquos programsimmediately after graduation and thenumber of employed RNs admitted toNP masterrsquos programs The linearprogramming approach combinesforecasts of workforce needs with thesystemrsquos dynamics to determineoptimal admission decisions and toidentify policy interventions thatwould improve system performance

We computed two performancemeasures to assess the quality of thelinear programming modelrsquosdecisions Our first performancemeasure was the absolute PNPshortage in the United States over the25-year horizon We defined shortageas the positive absolute difference

between the demand for PNPs(calculated on the basis of anassumed 5 annual demand growthwith respect to the currentworkforce24) in a given year and thesupply of PNPs in that year thereforeno shortage occurs whenever thesupply of PNPs in a year is equal to orexceeds the demand for PNPs in thatyear We assumed that demand forPNPs can only be satisfied by PNPsWe also calculated the expectednumber of years until the PNPworkforce system would be able tofully satisfy demand Thisperformance measure captured howlong the system needed to becomeself-sufficient (ie no PNP shortages)

We defined the best-case scenario asthe result of following the modelrsquosoptimal admission decisions underthe modeled systemrsquos currentvariables We use the best-casescenario as the basis for our analysisbecause it highlights the limitations ofthe current education and workforcesystem even when viewedconservatively When not followingoptimal admission decisions theforecasted shortages will bemagnified

Furthermore we performedsensitivity analysis of the systemrsquoscurrent variables to calculate theeffect of changing these variables onthe performance measures of thesystem This sensitivity analysisprovided a robust method forstudying the effect of policy changes(eg increased funding toward theexpansion of PNP masterrsquos programs)on the expected number of years untilthe PNP system is self-sufficient

RESULTS

Current System

Table 1 presents the base-case valuesfor inputs to the model The currentnursing education and workforcepipeline for PNPs has 299 118enrolled baccalaureate students2 763 000 working RNs2766 enrolled masterrsquos students in

300 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

PNP programs and 16 584 workingPNPs For the estimated annual PNPdemand growth of 5 even underthe best-case scenario for the currentPNP system it would take 13 years toachieve self-sufficiency (ie no PNPshortage) The shortage is a result ofincreased demand for PNPs in theworkforce a constrained educationsystem and the attrition of currentlyemployed PNPs

Figure 2 displays the absoluteshortage of PNPs in the workforceover the next 25 years for the currentsystem under 4 5 and 6 annualdemand growth The forecastedshortage depends strongly on theannual demand growth for PNPsCombining an accurate predictionmodel with optimal decision-makingprovides estimates of the value ofsystem changes such as an increasedPNP specialization rate

Next we present the sensitivityanalyses of 3 potential systemchanges increasing the PNP

specialization rate increasing thePNP examination passing rate andincreasing the potential annualenrollment growth rate of PNPmasterrsquos programs

PNP Specialization Rate

We started by investigating howmaking changes to the PNPspecialization rate (ranging from 2to 9) would affect the number ofyears required until the system nolonger experiences shortages in thebest-case scenario PNP specializationis the percentage of incoming NPmasterrsquos students who selectpediatrics as their nursing specialtyThe number of years required tobecome self-sufficient is highlydependent on the percentage ofstudents obtaining an NP masterrsquosdegree who choose to specialize inpediatrics As can be seen in Fig 3increases in PNP specialization wouldyield a higher supply of NP studentspursuing PNP education anda proportionally higher pool of PNPs

for satisfying demand The currentPNP specialization rate is 49 witha corresponding 13 years until thesystem is self-sufficient We foundthat the ideal PNP specialization rateis 89 This ideal specialization rateachieves the minimum expectednumber of years until self-sufficiencyof 5 years However just as improvedspecialization rates decrease thenumber of years until self-sufficiencyif the specialization rate decreases to37 the PNP shortage is expected topersist for 19 years under the best-case scenario

PNP Examination Passing Rate

We also studied how PNP nationalcertification examination passingrates influence our performancemeasure of the expected number ofyears required until the system isself-sufficient We computed thecurrent PNP examination passing ratenationwide (869) from thePediatric Nursing Certification Board201322 As shown in Fig 4 increasesin the PNP examination passing ratewould lead to more graduating PNPstudents certified to performpediatric care We found that byincreasing the PNP examinationpassing rate to 96 the number ofyears required until self-sufficiencywould decrease from 13 to 11Similarly if the examination passingrate decreases to 78 the number ofyears required until self-sufficiencywould increase from 13 to 15

PNP Masterrsquos Program Growth

Under the best-case scenario thecurrent system will require a nearquadrupling in the number of PNPgraduates over the next 25 years tosatisfy the assumed 5 annualdemand growth Over the last 5 yearswe observed a maximum percentageannual increase in the number ofmasterrsquos students of 107 Figure 5shows the effect of adding flexibilityin how much masterrsquos programs cangrow from year to year Increasing thepotential growth rate of theenrollment size of masterrsquos programs

TABLE 1 Base-Case Estimates for the Model Inputs

Variable Value Source

Initial number of students enrolled inbaccalaureate nursing programs n

299 118 American Association of Colleges in Nursingenrollment data18

Initial number of students enrolledin PNP masterrsquos programs n

2766 American Association of Colleges in Nursing18

Initial RN workforce size n 2 763 000 American Association of Colleges in Nursingshortage fact sheet23

Initial PNP workforce size n 16 584 National Association of Pediatric NursePractitioners24

RN annual attrition rate 3 National Sample Survey of Registered Nurses20

PNP annual attrition rate 15 Pediatric Nursing Certification Boardrecertification data19

Proportion of full-timepart-timetraditional undergraduatenursing students

90892 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-timeRN-baccalaureate undergraduatenursing students

327673 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-time PNPmasterrsquos students

382618 American Association of Colleges in Nursingenrollment data18

Maximum PNP masterrsquos programenrollment growth rate

107 American Association of Colleges in Nursingenrollment data18

RN examination passing rate 9221 National Council of State Boards of Nursing21

PNP examination passing rate 869 Pediatric Nursing Certification Board22

NP specialization rate 521 American Association of Colleges in Nursingenrollment data18

PNP specialization rate 49 American Association of Colleges in Nursingenrollment data18

PNP annual demand growth 5 National Association of Pediatric NursePractitioners2426

PEDIATRICS Volume 135 number 2 February 2015 301 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

leads to larger student populationswho enter the workforce aftergraduation and certification Theexpected number of years until

self-sufficiency would be reduced to5 years if the potential annual growthrate increased to 36 If the potentialannual growth rate of enrollment is

restricted to 8 the expectednumber of years until self-sufficiencywould increase to 22 years

DISCUSSION

Our linear programming modelcombines optimal decision-makingwith predictions of nationwide PNPdemand to evaluate the forecastedshortage of PNPs

Analysis of the current system revealsthat even under the best-casescenario the existing system will notsatisfy demand for PNPs in theworkforce for at least 13 yearsSatisfying this demand requiresfollowing the optimal admissiondecisions determined by our modelthe growing PNP demand will not besatisfied by the current system unlesschanges are made The insufficientsupply of PNPs may constrain accessto pediatric care which cannegatively affect childrenrsquos healthThrough sensitivity analysis of ourmodel we have identified 3 systemchanges that would reduce theforecasted PNP shortage and theexpected number of years untilthe system is self-sufficient (1)increasing the percentage of NPmasterrsquos students choosing pediatricsas their specialty (2) increasing thePNP certification examination passingrate and (3) increasing the potentialannual growth in enrollment of PNPmasterrsquos programs

PNP Specialization

Presently only 49 of NP graduatestudents choose to specialize inpediatric care The primary reason NPmasterrsquos students specialize inpediatrics is their desire to work withchildren29 For those who specializedin pediatrics the primary alternativespecialization was FNP29 Thepopularity of FNPs (a doubling in thenumber of FNP graduates between1996 and 2008) may be due to theirperceived job flexibility in being ableto work with patients of any age30 Infact the vast majority of FNPs (93)treat patients between the ages of

FIGURE 2Annual absolute PNP shortage under 3 assumptions about annual PNP demand growth (1) 4growth per year (2) 5 growth per year (baseline) and (3) 6 growth per year Note that from year19 to 25 the absolute PNP shortage is 0

FIGURE 3The PNP specialization rate is the percentage of NP masterrsquos students who choose to study pedi-atrics as their nursing specialty The expected years required to be self-sufficient is defined as theminimum number of years until the system experiences no shortages of PNPs under the best-casescenario The dashed lines indicate the current PNP specialization rate and expected years requiredto be self-sufficient

302 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

66 and 85 years and 79 of FNPstreat patients older than 85 years31

Moreover one-third of FNPs reportedthat they did not provide care tochildren and for most of those who

did report care to children thesechildren (especially those 8 yearsold) were a small percentage of theirpatient populations4 Hence masterrsquosstudents pursuing FNP education

with the intention of caring forchildren during their career may notprovide care to children when theyare practicing as FNPs Attentionmust be paid to these workforcerealities during the course of nursingeducation to ensure that studentsmake well-informed career choicesBecause many NP students perceiveFNPs as having higher job availabilitythan PNPs increasing the PNPspecialization rate will requireimproved marketing of the PNP asa career at all potential points ofnursing career decision-makingbefore Bachelor of Science in Nursingprograms during time as an RN andupon entrance to advanced educationprograms This marketing may takethe form of messages from nursingfaculty and clinical preceptors tostudents or through increased mediaemphasis on the need for PNPs andtheir unique role in the care ofchildren

The Robert Wood JohnsonFoundation Committee on the Futureof Nursing at the Institute of Medicinerecommends an increase inscholarships loan forgiveness andinstitutional capacity awards toincrease the number and proportionof newly licensed nurses graduatingfrom higher degree programs12

Scholarships and loan forgivenesstargeted at PNP graduate studentswill incentivize specialization in PNP

Although our analysis indicates thatan increase in the PNP specializationrate is necessary to meet the demandmore PNPs do not need to come atthe expense of other NP specialtiesOverall increases in NP enrollmentwould also satisfy the need for morePNPs without changing thepercentage of NPs who choosepediatrics

PNP Examination Passing Rate

The current national PNPexamination passing rate forcertification is 869 with variationacross the United States Withoutcertification in most states a student

FIGURE 4The PNP certification examination passing rate is the percentage of PNP graduate students who passthe PNP certification examination in their state upon graduation The expected years required to beself-sufficient is defined as the minimum number of years until the system experiences no shortagesof PNPs under the best-case scenario The dashed lines indicate the current PNP exam passing rateand expected years required to be self-sufficient

FIGURE 5The potential growth rate of masterrsquos programs is the maximum annual increase in PNP masterrsquosprogram enrollment The expected years required to be self-sufficient is defined as the minimumnumber of years until the system experiences no shortages of PNPs under the best-case scenarioThe dashed lines indicate the current potential growth rate of enrollment and expected yearsrequired to be self-sufficient

PEDIATRICS Volume 135 number 2 February 2015 303 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

the graduated student either enteredthe RN workforce after passing theRN examination or enrolled in an NPmasterrsquos program Our modeling alsoallowed employed RNs to exit theworkforce and enroll in an NPmasterrsquos program while ensuringa minimum number of RNs remain inthe workforce Of those who enrolledin an NP masterrsquos program in a givenyear the PNP specialization ratedefined the percentage of enrolled NPmasterrsquos students who selected PNPas their specialty and hence becamePNP masterrsquos students PNP masterrsquosstudents were categorized as eitherfull-time or part-time students Full-time masterrsquos students completedtheir degree in 2 years whereas part-time students completed their degreein 3 to 5 years Upon graduation fromthe PNP masterrsquos program thegraduated student entered theworkforce after passing the nationalPNP certification examinationFurthermore at each education andprofessional category (eg third-yearbachelorrsquos student) enrolled studentsand employed RNs and PNPs wereallowed to exit the education orworkforce system (ie we modeledboth education and workforceattrition) Attrition rates for eachcategory were computed as thepercentage of studentsnurses whowould leave the educationworkforcesystem each year

We used data and categories fromEnrollment and Graduations inBaccalaureate and GraduatePrograms in Nursing by the AmericanAssociation of Colleges in Nursing(AACN)18 to compute initialpopulation sizes attrition rates andgraduation rates for baccalaureateand masterrsquos nursing students Fromthe AACN we also computed the rateof students entering nursing masterrsquosprograms who specialize in NP andthe rate of NP students specializing inPNP The attrition rate of PNPs fromthe workforce was computed byusing recertification rates between2011 and 2013 from the PediatricNursing Certification Board19

Attrition rate of RNs from theworkforce were calculated from theNational Sample Survey of RegisteredNurses20 RN and PNP examinationpassing rates were calculated fromthe National Council of State Boardsof Nursing21 and the PediatricNursing Certification Board22

respectively Data for the initialworkforce levels of RNs and PNPscame from the AACN NursingShortage Fact Sheet23 and theNational Association of PediatricNurse Practitioners 2013 StateMap24 respectively Payroll costs forRNs FNPs and PNPs came from theUS Department of Laborrsquos Bureau ofLabor Statistics25 Annual demandgrowth for PNPs in the workforce(5) was computed as the averageannual change in the number of PNPsin the United States from 2009 to20132426

We used linear programming todetermine optimal admissiondecisions every year of the planninghorizon (25 years) that would lead tosatisfying the demand for PNPs27

The approach used to model the PNPworkforce and to derive optimaldecisions is described in Lavieri andPuterman28 The optimal admissiondecisions for a particular year are thenumber of students admitted tonursing baccalaureate programs thenumber of bachelorrsquos studentsadmitted to NP masterrsquos programsimmediately after graduation and thenumber of employed RNs admitted toNP masterrsquos programs The linearprogramming approach combinesforecasts of workforce needs with thesystemrsquos dynamics to determineoptimal admission decisions and toidentify policy interventions thatwould improve system performance

We computed two performancemeasures to assess the quality of thelinear programming modelrsquosdecisions Our first performancemeasure was the absolute PNPshortage in the United States over the25-year horizon We defined shortageas the positive absolute difference

between the demand for PNPs(calculated on the basis of anassumed 5 annual demand growthwith respect to the currentworkforce24) in a given year and thesupply of PNPs in that year thereforeno shortage occurs whenever thesupply of PNPs in a year is equal to orexceeds the demand for PNPs in thatyear We assumed that demand forPNPs can only be satisfied by PNPsWe also calculated the expectednumber of years until the PNPworkforce system would be able tofully satisfy demand Thisperformance measure captured howlong the system needed to becomeself-sufficient (ie no PNP shortages)

We defined the best-case scenario asthe result of following the modelrsquosoptimal admission decisions underthe modeled systemrsquos currentvariables We use the best-casescenario as the basis for our analysisbecause it highlights the limitations ofthe current education and workforcesystem even when viewedconservatively When not followingoptimal admission decisions theforecasted shortages will bemagnified

Furthermore we performedsensitivity analysis of the systemrsquoscurrent variables to calculate theeffect of changing these variables onthe performance measures of thesystem This sensitivity analysisprovided a robust method forstudying the effect of policy changes(eg increased funding toward theexpansion of PNP masterrsquos programs)on the expected number of years untilthe PNP system is self-sufficient

RESULTS

Current System

Table 1 presents the base-case valuesfor inputs to the model The currentnursing education and workforcepipeline for PNPs has 299 118enrolled baccalaureate students2 763 000 working RNs2766 enrolled masterrsquos students in

300 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

PNP programs and 16 584 workingPNPs For the estimated annual PNPdemand growth of 5 even underthe best-case scenario for the currentPNP system it would take 13 years toachieve self-sufficiency (ie no PNPshortage) The shortage is a result ofincreased demand for PNPs in theworkforce a constrained educationsystem and the attrition of currentlyemployed PNPs

Figure 2 displays the absoluteshortage of PNPs in the workforceover the next 25 years for the currentsystem under 4 5 and 6 annualdemand growth The forecastedshortage depends strongly on theannual demand growth for PNPsCombining an accurate predictionmodel with optimal decision-makingprovides estimates of the value ofsystem changes such as an increasedPNP specialization rate

Next we present the sensitivityanalyses of 3 potential systemchanges increasing the PNP

specialization rate increasing thePNP examination passing rate andincreasing the potential annualenrollment growth rate of PNPmasterrsquos programs

PNP Specialization Rate

We started by investigating howmaking changes to the PNPspecialization rate (ranging from 2to 9) would affect the number ofyears required until the system nolonger experiences shortages in thebest-case scenario PNP specializationis the percentage of incoming NPmasterrsquos students who selectpediatrics as their nursing specialtyThe number of years required tobecome self-sufficient is highlydependent on the percentage ofstudents obtaining an NP masterrsquosdegree who choose to specialize inpediatrics As can be seen in Fig 3increases in PNP specialization wouldyield a higher supply of NP studentspursuing PNP education anda proportionally higher pool of PNPs

for satisfying demand The currentPNP specialization rate is 49 witha corresponding 13 years until thesystem is self-sufficient We foundthat the ideal PNP specialization rateis 89 This ideal specialization rateachieves the minimum expectednumber of years until self-sufficiencyof 5 years However just as improvedspecialization rates decrease thenumber of years until self-sufficiencyif the specialization rate decreases to37 the PNP shortage is expected topersist for 19 years under the best-case scenario

PNP Examination Passing Rate

We also studied how PNP nationalcertification examination passingrates influence our performancemeasure of the expected number ofyears required until the system isself-sufficient We computed thecurrent PNP examination passing ratenationwide (869) from thePediatric Nursing Certification Board201322 As shown in Fig 4 increasesin the PNP examination passing ratewould lead to more graduating PNPstudents certified to performpediatric care We found that byincreasing the PNP examinationpassing rate to 96 the number ofyears required until self-sufficiencywould decrease from 13 to 11Similarly if the examination passingrate decreases to 78 the number ofyears required until self-sufficiencywould increase from 13 to 15

PNP Masterrsquos Program Growth

Under the best-case scenario thecurrent system will require a nearquadrupling in the number of PNPgraduates over the next 25 years tosatisfy the assumed 5 annualdemand growth Over the last 5 yearswe observed a maximum percentageannual increase in the number ofmasterrsquos students of 107 Figure 5shows the effect of adding flexibilityin how much masterrsquos programs cangrow from year to year Increasing thepotential growth rate of theenrollment size of masterrsquos programs

TABLE 1 Base-Case Estimates for the Model Inputs

Variable Value Source

Initial number of students enrolled inbaccalaureate nursing programs n

299 118 American Association of Colleges in Nursingenrollment data18

Initial number of students enrolledin PNP masterrsquos programs n

2766 American Association of Colleges in Nursing18

Initial RN workforce size n 2 763 000 American Association of Colleges in Nursingshortage fact sheet23

Initial PNP workforce size n 16 584 National Association of Pediatric NursePractitioners24

RN annual attrition rate 3 National Sample Survey of Registered Nurses20

PNP annual attrition rate 15 Pediatric Nursing Certification Boardrecertification data19

Proportion of full-timepart-timetraditional undergraduatenursing students

90892 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-timeRN-baccalaureate undergraduatenursing students

327673 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-time PNPmasterrsquos students

382618 American Association of Colleges in Nursingenrollment data18

Maximum PNP masterrsquos programenrollment growth rate

107 American Association of Colleges in Nursingenrollment data18

RN examination passing rate 9221 National Council of State Boards of Nursing21

PNP examination passing rate 869 Pediatric Nursing Certification Board22

NP specialization rate 521 American Association of Colleges in Nursingenrollment data18

PNP specialization rate 49 American Association of Colleges in Nursingenrollment data18

PNP annual demand growth 5 National Association of Pediatric NursePractitioners2426

PEDIATRICS Volume 135 number 2 February 2015 301 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

leads to larger student populationswho enter the workforce aftergraduation and certification Theexpected number of years until

self-sufficiency would be reduced to5 years if the potential annual growthrate increased to 36 If the potentialannual growth rate of enrollment is

restricted to 8 the expectednumber of years until self-sufficiencywould increase to 22 years

DISCUSSION

Our linear programming modelcombines optimal decision-makingwith predictions of nationwide PNPdemand to evaluate the forecastedshortage of PNPs

Analysis of the current system revealsthat even under the best-casescenario the existing system will notsatisfy demand for PNPs in theworkforce for at least 13 yearsSatisfying this demand requiresfollowing the optimal admissiondecisions determined by our modelthe growing PNP demand will not besatisfied by the current system unlesschanges are made The insufficientsupply of PNPs may constrain accessto pediatric care which cannegatively affect childrenrsquos healthThrough sensitivity analysis of ourmodel we have identified 3 systemchanges that would reduce theforecasted PNP shortage and theexpected number of years untilthe system is self-sufficient (1)increasing the percentage of NPmasterrsquos students choosing pediatricsas their specialty (2) increasing thePNP certification examination passingrate and (3) increasing the potentialannual growth in enrollment of PNPmasterrsquos programs

PNP Specialization

Presently only 49 of NP graduatestudents choose to specialize inpediatric care The primary reason NPmasterrsquos students specialize inpediatrics is their desire to work withchildren29 For those who specializedin pediatrics the primary alternativespecialization was FNP29 Thepopularity of FNPs (a doubling in thenumber of FNP graduates between1996 and 2008) may be due to theirperceived job flexibility in being ableto work with patients of any age30 Infact the vast majority of FNPs (93)treat patients between the ages of

FIGURE 2Annual absolute PNP shortage under 3 assumptions about annual PNP demand growth (1) 4growth per year (2) 5 growth per year (baseline) and (3) 6 growth per year Note that from year19 to 25 the absolute PNP shortage is 0

FIGURE 3The PNP specialization rate is the percentage of NP masterrsquos students who choose to study pedi-atrics as their nursing specialty The expected years required to be self-sufficient is defined as theminimum number of years until the system experiences no shortages of PNPs under the best-casescenario The dashed lines indicate the current PNP specialization rate and expected years requiredto be self-sufficient

302 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

66 and 85 years and 79 of FNPstreat patients older than 85 years31

Moreover one-third of FNPs reportedthat they did not provide care tochildren and for most of those who

did report care to children thesechildren (especially those 8 yearsold) were a small percentage of theirpatient populations4 Hence masterrsquosstudents pursuing FNP education

with the intention of caring forchildren during their career may notprovide care to children when theyare practicing as FNPs Attentionmust be paid to these workforcerealities during the course of nursingeducation to ensure that studentsmake well-informed career choicesBecause many NP students perceiveFNPs as having higher job availabilitythan PNPs increasing the PNPspecialization rate will requireimproved marketing of the PNP asa career at all potential points ofnursing career decision-makingbefore Bachelor of Science in Nursingprograms during time as an RN andupon entrance to advanced educationprograms This marketing may takethe form of messages from nursingfaculty and clinical preceptors tostudents or through increased mediaemphasis on the need for PNPs andtheir unique role in the care ofchildren

The Robert Wood JohnsonFoundation Committee on the Futureof Nursing at the Institute of Medicinerecommends an increase inscholarships loan forgiveness andinstitutional capacity awards toincrease the number and proportionof newly licensed nurses graduatingfrom higher degree programs12

Scholarships and loan forgivenesstargeted at PNP graduate studentswill incentivize specialization in PNP

Although our analysis indicates thatan increase in the PNP specializationrate is necessary to meet the demandmore PNPs do not need to come atthe expense of other NP specialtiesOverall increases in NP enrollmentwould also satisfy the need for morePNPs without changing thepercentage of NPs who choosepediatrics

PNP Examination Passing Rate

The current national PNPexamination passing rate forcertification is 869 with variationacross the United States Withoutcertification in most states a student

FIGURE 4The PNP certification examination passing rate is the percentage of PNP graduate students who passthe PNP certification examination in their state upon graduation The expected years required to beself-sufficient is defined as the minimum number of years until the system experiences no shortagesof PNPs under the best-case scenario The dashed lines indicate the current PNP exam passing rateand expected years required to be self-sufficient

FIGURE 5The potential growth rate of masterrsquos programs is the maximum annual increase in PNP masterrsquosprogram enrollment The expected years required to be self-sufficient is defined as the minimumnumber of years until the system experiences no shortages of PNPs under the best-case scenarioThe dashed lines indicate the current potential growth rate of enrollment and expected yearsrequired to be self-sufficient

PEDIATRICS Volume 135 number 2 February 2015 303 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

PNP programs and 16 584 workingPNPs For the estimated annual PNPdemand growth of 5 even underthe best-case scenario for the currentPNP system it would take 13 years toachieve self-sufficiency (ie no PNPshortage) The shortage is a result ofincreased demand for PNPs in theworkforce a constrained educationsystem and the attrition of currentlyemployed PNPs

Figure 2 displays the absoluteshortage of PNPs in the workforceover the next 25 years for the currentsystem under 4 5 and 6 annualdemand growth The forecastedshortage depends strongly on theannual demand growth for PNPsCombining an accurate predictionmodel with optimal decision-makingprovides estimates of the value ofsystem changes such as an increasedPNP specialization rate

Next we present the sensitivityanalyses of 3 potential systemchanges increasing the PNP

specialization rate increasing thePNP examination passing rate andincreasing the potential annualenrollment growth rate of PNPmasterrsquos programs

PNP Specialization Rate

We started by investigating howmaking changes to the PNPspecialization rate (ranging from 2to 9) would affect the number ofyears required until the system nolonger experiences shortages in thebest-case scenario PNP specializationis the percentage of incoming NPmasterrsquos students who selectpediatrics as their nursing specialtyThe number of years required tobecome self-sufficient is highlydependent on the percentage ofstudents obtaining an NP masterrsquosdegree who choose to specialize inpediatrics As can be seen in Fig 3increases in PNP specialization wouldyield a higher supply of NP studentspursuing PNP education anda proportionally higher pool of PNPs

for satisfying demand The currentPNP specialization rate is 49 witha corresponding 13 years until thesystem is self-sufficient We foundthat the ideal PNP specialization rateis 89 This ideal specialization rateachieves the minimum expectednumber of years until self-sufficiencyof 5 years However just as improvedspecialization rates decrease thenumber of years until self-sufficiencyif the specialization rate decreases to37 the PNP shortage is expected topersist for 19 years under the best-case scenario

PNP Examination Passing Rate

We also studied how PNP nationalcertification examination passingrates influence our performancemeasure of the expected number ofyears required until the system isself-sufficient We computed thecurrent PNP examination passing ratenationwide (869) from thePediatric Nursing Certification Board201322 As shown in Fig 4 increasesin the PNP examination passing ratewould lead to more graduating PNPstudents certified to performpediatric care We found that byincreasing the PNP examinationpassing rate to 96 the number ofyears required until self-sufficiencywould decrease from 13 to 11Similarly if the examination passingrate decreases to 78 the number ofyears required until self-sufficiencywould increase from 13 to 15

PNP Masterrsquos Program Growth

Under the best-case scenario thecurrent system will require a nearquadrupling in the number of PNPgraduates over the next 25 years tosatisfy the assumed 5 annualdemand growth Over the last 5 yearswe observed a maximum percentageannual increase in the number ofmasterrsquos students of 107 Figure 5shows the effect of adding flexibilityin how much masterrsquos programs cangrow from year to year Increasing thepotential growth rate of theenrollment size of masterrsquos programs

TABLE 1 Base-Case Estimates for the Model Inputs

Variable Value Source

Initial number of students enrolled inbaccalaureate nursing programs n

299 118 American Association of Colleges in Nursingenrollment data18

Initial number of students enrolledin PNP masterrsquos programs n

2766 American Association of Colleges in Nursing18

Initial RN workforce size n 2 763 000 American Association of Colleges in Nursingshortage fact sheet23

Initial PNP workforce size n 16 584 National Association of Pediatric NursePractitioners24

RN annual attrition rate 3 National Sample Survey of Registered Nurses20

PNP annual attrition rate 15 Pediatric Nursing Certification Boardrecertification data19

Proportion of full-timepart-timetraditional undergraduatenursing students

90892 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-timeRN-baccalaureate undergraduatenursing students

327673 American Association of Colleges in Nursingenrollment data18

Proportion of full-timepart-time PNPmasterrsquos students

382618 American Association of Colleges in Nursingenrollment data18

Maximum PNP masterrsquos programenrollment growth rate

107 American Association of Colleges in Nursingenrollment data18

RN examination passing rate 9221 National Council of State Boards of Nursing21

PNP examination passing rate 869 Pediatric Nursing Certification Board22

NP specialization rate 521 American Association of Colleges in Nursingenrollment data18

PNP specialization rate 49 American Association of Colleges in Nursingenrollment data18

PNP annual demand growth 5 National Association of Pediatric NursePractitioners2426

PEDIATRICS Volume 135 number 2 February 2015 301 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

leads to larger student populationswho enter the workforce aftergraduation and certification Theexpected number of years until

self-sufficiency would be reduced to5 years if the potential annual growthrate increased to 36 If the potentialannual growth rate of enrollment is

restricted to 8 the expectednumber of years until self-sufficiencywould increase to 22 years

DISCUSSION

Our linear programming modelcombines optimal decision-makingwith predictions of nationwide PNPdemand to evaluate the forecastedshortage of PNPs

Analysis of the current system revealsthat even under the best-casescenario the existing system will notsatisfy demand for PNPs in theworkforce for at least 13 yearsSatisfying this demand requiresfollowing the optimal admissiondecisions determined by our modelthe growing PNP demand will not besatisfied by the current system unlesschanges are made The insufficientsupply of PNPs may constrain accessto pediatric care which cannegatively affect childrenrsquos healthThrough sensitivity analysis of ourmodel we have identified 3 systemchanges that would reduce theforecasted PNP shortage and theexpected number of years untilthe system is self-sufficient (1)increasing the percentage of NPmasterrsquos students choosing pediatricsas their specialty (2) increasing thePNP certification examination passingrate and (3) increasing the potentialannual growth in enrollment of PNPmasterrsquos programs

PNP Specialization

Presently only 49 of NP graduatestudents choose to specialize inpediatric care The primary reason NPmasterrsquos students specialize inpediatrics is their desire to work withchildren29 For those who specializedin pediatrics the primary alternativespecialization was FNP29 Thepopularity of FNPs (a doubling in thenumber of FNP graduates between1996 and 2008) may be due to theirperceived job flexibility in being ableto work with patients of any age30 Infact the vast majority of FNPs (93)treat patients between the ages of

FIGURE 2Annual absolute PNP shortage under 3 assumptions about annual PNP demand growth (1) 4growth per year (2) 5 growth per year (baseline) and (3) 6 growth per year Note that from year19 to 25 the absolute PNP shortage is 0

FIGURE 3The PNP specialization rate is the percentage of NP masterrsquos students who choose to study pedi-atrics as their nursing specialty The expected years required to be self-sufficient is defined as theminimum number of years until the system experiences no shortages of PNPs under the best-casescenario The dashed lines indicate the current PNP specialization rate and expected years requiredto be self-sufficient

302 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

66 and 85 years and 79 of FNPstreat patients older than 85 years31

Moreover one-third of FNPs reportedthat they did not provide care tochildren and for most of those who

did report care to children thesechildren (especially those 8 yearsold) were a small percentage of theirpatient populations4 Hence masterrsquosstudents pursuing FNP education

with the intention of caring forchildren during their career may notprovide care to children when theyare practicing as FNPs Attentionmust be paid to these workforcerealities during the course of nursingeducation to ensure that studentsmake well-informed career choicesBecause many NP students perceiveFNPs as having higher job availabilitythan PNPs increasing the PNPspecialization rate will requireimproved marketing of the PNP asa career at all potential points ofnursing career decision-makingbefore Bachelor of Science in Nursingprograms during time as an RN andupon entrance to advanced educationprograms This marketing may takethe form of messages from nursingfaculty and clinical preceptors tostudents or through increased mediaemphasis on the need for PNPs andtheir unique role in the care ofchildren

The Robert Wood JohnsonFoundation Committee on the Futureof Nursing at the Institute of Medicinerecommends an increase inscholarships loan forgiveness andinstitutional capacity awards toincrease the number and proportionof newly licensed nurses graduatingfrom higher degree programs12

Scholarships and loan forgivenesstargeted at PNP graduate studentswill incentivize specialization in PNP

Although our analysis indicates thatan increase in the PNP specializationrate is necessary to meet the demandmore PNPs do not need to come atthe expense of other NP specialtiesOverall increases in NP enrollmentwould also satisfy the need for morePNPs without changing thepercentage of NPs who choosepediatrics

PNP Examination Passing Rate

The current national PNPexamination passing rate forcertification is 869 with variationacross the United States Withoutcertification in most states a student

FIGURE 4The PNP certification examination passing rate is the percentage of PNP graduate students who passthe PNP certification examination in their state upon graduation The expected years required to beself-sufficient is defined as the minimum number of years until the system experiences no shortagesof PNPs under the best-case scenario The dashed lines indicate the current PNP exam passing rateand expected years required to be self-sufficient

FIGURE 5The potential growth rate of masterrsquos programs is the maximum annual increase in PNP masterrsquosprogram enrollment The expected years required to be self-sufficient is defined as the minimumnumber of years until the system experiences no shortages of PNPs under the best-case scenarioThe dashed lines indicate the current potential growth rate of enrollment and expected yearsrequired to be self-sufficient

PEDIATRICS Volume 135 number 2 February 2015 303 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

leads to larger student populationswho enter the workforce aftergraduation and certification Theexpected number of years until

self-sufficiency would be reduced to5 years if the potential annual growthrate increased to 36 If the potentialannual growth rate of enrollment is

restricted to 8 the expectednumber of years until self-sufficiencywould increase to 22 years

DISCUSSION

Our linear programming modelcombines optimal decision-makingwith predictions of nationwide PNPdemand to evaluate the forecastedshortage of PNPs

Analysis of the current system revealsthat even under the best-casescenario the existing system will notsatisfy demand for PNPs in theworkforce for at least 13 yearsSatisfying this demand requiresfollowing the optimal admissiondecisions determined by our modelthe growing PNP demand will not besatisfied by the current system unlesschanges are made The insufficientsupply of PNPs may constrain accessto pediatric care which cannegatively affect childrenrsquos healthThrough sensitivity analysis of ourmodel we have identified 3 systemchanges that would reduce theforecasted PNP shortage and theexpected number of years untilthe system is self-sufficient (1)increasing the percentage of NPmasterrsquos students choosing pediatricsas their specialty (2) increasing thePNP certification examination passingrate and (3) increasing the potentialannual growth in enrollment of PNPmasterrsquos programs

PNP Specialization

Presently only 49 of NP graduatestudents choose to specialize inpediatric care The primary reason NPmasterrsquos students specialize inpediatrics is their desire to work withchildren29 For those who specializedin pediatrics the primary alternativespecialization was FNP29 Thepopularity of FNPs (a doubling in thenumber of FNP graduates between1996 and 2008) may be due to theirperceived job flexibility in being ableto work with patients of any age30 Infact the vast majority of FNPs (93)treat patients between the ages of

FIGURE 2Annual absolute PNP shortage under 3 assumptions about annual PNP demand growth (1) 4growth per year (2) 5 growth per year (baseline) and (3) 6 growth per year Note that from year19 to 25 the absolute PNP shortage is 0

FIGURE 3The PNP specialization rate is the percentage of NP masterrsquos students who choose to study pedi-atrics as their nursing specialty The expected years required to be self-sufficient is defined as theminimum number of years until the system experiences no shortages of PNPs under the best-casescenario The dashed lines indicate the current PNP specialization rate and expected years requiredto be self-sufficient

302 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

66 and 85 years and 79 of FNPstreat patients older than 85 years31

Moreover one-third of FNPs reportedthat they did not provide care tochildren and for most of those who

did report care to children thesechildren (especially those 8 yearsold) were a small percentage of theirpatient populations4 Hence masterrsquosstudents pursuing FNP education

with the intention of caring forchildren during their career may notprovide care to children when theyare practicing as FNPs Attentionmust be paid to these workforcerealities during the course of nursingeducation to ensure that studentsmake well-informed career choicesBecause many NP students perceiveFNPs as having higher job availabilitythan PNPs increasing the PNPspecialization rate will requireimproved marketing of the PNP asa career at all potential points ofnursing career decision-makingbefore Bachelor of Science in Nursingprograms during time as an RN andupon entrance to advanced educationprograms This marketing may takethe form of messages from nursingfaculty and clinical preceptors tostudents or through increased mediaemphasis on the need for PNPs andtheir unique role in the care ofchildren

The Robert Wood JohnsonFoundation Committee on the Futureof Nursing at the Institute of Medicinerecommends an increase inscholarships loan forgiveness andinstitutional capacity awards toincrease the number and proportionof newly licensed nurses graduatingfrom higher degree programs12

Scholarships and loan forgivenesstargeted at PNP graduate studentswill incentivize specialization in PNP

Although our analysis indicates thatan increase in the PNP specializationrate is necessary to meet the demandmore PNPs do not need to come atthe expense of other NP specialtiesOverall increases in NP enrollmentwould also satisfy the need for morePNPs without changing thepercentage of NPs who choosepediatrics

PNP Examination Passing Rate

The current national PNPexamination passing rate forcertification is 869 with variationacross the United States Withoutcertification in most states a student

FIGURE 4The PNP certification examination passing rate is the percentage of PNP graduate students who passthe PNP certification examination in their state upon graduation The expected years required to beself-sufficient is defined as the minimum number of years until the system experiences no shortagesof PNPs under the best-case scenario The dashed lines indicate the current PNP exam passing rateand expected years required to be self-sufficient

FIGURE 5The potential growth rate of masterrsquos programs is the maximum annual increase in PNP masterrsquosprogram enrollment The expected years required to be self-sufficient is defined as the minimumnumber of years until the system experiences no shortages of PNPs under the best-case scenarioThe dashed lines indicate the current potential growth rate of enrollment and expected yearsrequired to be self-sufficient

PEDIATRICS Volume 135 number 2 February 2015 303 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

66 and 85 years and 79 of FNPstreat patients older than 85 years31

Moreover one-third of FNPs reportedthat they did not provide care tochildren and for most of those who

did report care to children thesechildren (especially those 8 yearsold) were a small percentage of theirpatient populations4 Hence masterrsquosstudents pursuing FNP education

with the intention of caring forchildren during their career may notprovide care to children when theyare practicing as FNPs Attentionmust be paid to these workforcerealities during the course of nursingeducation to ensure that studentsmake well-informed career choicesBecause many NP students perceiveFNPs as having higher job availabilitythan PNPs increasing the PNPspecialization rate will requireimproved marketing of the PNP asa career at all potential points ofnursing career decision-makingbefore Bachelor of Science in Nursingprograms during time as an RN andupon entrance to advanced educationprograms This marketing may takethe form of messages from nursingfaculty and clinical preceptors tostudents or through increased mediaemphasis on the need for PNPs andtheir unique role in the care ofchildren

The Robert Wood JohnsonFoundation Committee on the Futureof Nursing at the Institute of Medicinerecommends an increase inscholarships loan forgiveness andinstitutional capacity awards toincrease the number and proportionof newly licensed nurses graduatingfrom higher degree programs12

Scholarships and loan forgivenesstargeted at PNP graduate studentswill incentivize specialization in PNP

Although our analysis indicates thatan increase in the PNP specializationrate is necessary to meet the demandmore PNPs do not need to come atthe expense of other NP specialtiesOverall increases in NP enrollmentwould also satisfy the need for morePNPs without changing thepercentage of NPs who choosepediatrics

PNP Examination Passing Rate

The current national PNPexamination passing rate forcertification is 869 with variationacross the United States Withoutcertification in most states a student

FIGURE 4The PNP certification examination passing rate is the percentage of PNP graduate students who passthe PNP certification examination in their state upon graduation The expected years required to beself-sufficient is defined as the minimum number of years until the system experiences no shortagesof PNPs under the best-case scenario The dashed lines indicate the current PNP exam passing rateand expected years required to be self-sufficient

FIGURE 5The potential growth rate of masterrsquos programs is the maximum annual increase in PNP masterrsquosprogram enrollment The expected years required to be self-sufficient is defined as the minimumnumber of years until the system experiences no shortages of PNPs under the best-case scenarioThe dashed lines indicate the current potential growth rate of enrollment and expected yearsrequired to be self-sufficient

PEDIATRICS Volume 135 number 2 February 2015 303 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

graduating from a PNP academicprogram will be unable to practice asa PNP Thus although increasing thepercentage of NP masterrsquos studentswho choose to specialize in pediatricswill increase enrollment in PNPmasterrsquos programs a lowercertification examination passing ratewill reduce gains in the PNPworkforce There is a need fornursing programs to focus on ways toimprove national certificationexamination pass rates to ensure thatgraduating students are able to jointhe workforce

The Robert Wood JohnsonFoundationInstitute of MedicineCommittee recommends thepromotion of innovation and theevaluation of novel approaches toimproving preparation for thepractice of nursing through expandedTitle VIII funding12 We recommendfunding collaborative analysis ofeducational methods andcollaboration of nursing faculty andcertification boards to increase thePNP examination passing rate

Enrollment Size of PNP MasterrsquosPrograms

There has been an increase in theproportion of NP programs that offeradvanced clinical education buta decrease in the proportion ofprograms offering PNP education1

Furthermore nursing programsnationwide face a shortage ofpediatric faculty members30 Thisreduced exposure to pediatric clinicalexperience is negatively affecting thenationrsquos ability to satisfy futuredemand for PNPs If the interest inPNP specialization increases theincreased demand for PNP educationwill ideally lead to increases in thenumber of PNP masterrsquos programsandor the enrollment size of existingPNP programs

An expansion in the size of PNPgraduate education programs willrequire increased funding formasterrsquos programs The AmericanNurses Association urges significant

increases in federal funding of theTitle VIII Nursing WorkforceDevelopment programs administeredby the Health Resources and ServicesAdministration of the US Departmentof Health and Human Services32

These programs provide grants toenhance education and practice formasterrsquos nursing students They alsoinclude the Nurse Educational LoanRepayment Program which supportsstudents enrolled in nursing with therequirement of at least 2 years offull-time employment in a facilitydesignated as having a criticalnursing shortage And althoughcomprehensive geriatric educationgrants assist in the training of nursesto provide for geriatric care we haveidentified a need for a similar grantprogram for pediatric nurseeducation

Implementing policies that yield thedesired change in the 3 systemvariables (PNP specialization rateexamination passing rate andenrollment sizes) requires significantfinancial investment in the marketingrecruitment and education of PNPsFor example monetary incentivesduring education (eg scholarships)may not be sufficient for increasingthe PNP specialization rate from 49to 89 Workplace incentives suchas pay increases may be necessary todraw highly qualified and motivatedstudents into the PNP field Theaverage annual salary for FNPs is$91 450 whereas the average salaryfor PNPs is $88 56225 Reducing thispay differential could lead to increasedspecialization in pediatric care Thefinancial burden of improving theaverage PNP salary is on employersand the medical system at largewhereas the PNP masterrsquos programsbenefit from the increased enrollmentat no expense Similarly if educationalprograms offer scholarships toincrease the specialization rateexpand their facilities and hire morefaculty members to accommodatemore students employers of thosegraduating students benefit at noexpense The relationship between

the education system and theworkplace necessitates a joint effortwith investment from both entities toeffectively resolve the forecasted PNPshortage

Study Limitations

Our estimate of annual demandgrowth was based on the observedaverage annual percentage growth inthe number of employed PNPs in theUnited States between 2009 and2013 We assumed that thispercentage growth will be constant inthe future and drives when self-sufficiency can be reached Because ofthe uncertainty of this demandgrowth as well as other modelvariables we have performedextensive sensitivity analysis aroundour estimate Furthermore wemodeled the aggregate PNPworkforce in the United StatesAdditional insights would be gained ifspecific roles of PNPs were examinedor if we considered other health careprofessionals such as physicianassistants as possible sources tosatisfy PNP demand Our model alsodoes not consider the particularproductivity of PNPs Future researchis needed to study how specific rolesand productivity of PNPs wouldimpact the forecasted shortage ofPNPs Our model also assumes thatannual attrition rates are equal for allPNPs and RNs regardless of ageFuture research will requireexpanding the model to include age-based attrition distributions

Our model assumes that demand forPNPs can only be satisfied byemployed PNPs The majority of PNPsin primary and subspecialty careperform most general practice rolesincluding the development oftreatment plans as well as assessingand diagnosing patients33 Howeverthe roles of PNPs may becomplemented or substituted byother pediatric health careprofessionals (eg pediatric physicianassistants) Because of their trainingand current roles in the hospitalsetting NPs and physician assistants

304 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

have both been identified asa potential solution for offsetting theforecasted physician shortage andincreasing access to care34 Futureresearch shall investigate theinteraction between these pediatrichealth care professionals in satisfyingdemand for pediatric servicesNeonatal NPs are also a concern andwill be the focus of a future project

Other factors may also impact thesupply of PNPs in the workforceThese include longer education timeand substitution of PNPs by physicianassistants or pediatricians Futureresearch will investigate the effects ofsuch system changes on theforecasted PNP shortage

Conclusions

We have developed a new method forcombining optimal admissiondecisions with forecasts of PNPsupply and demand to evaluate thePNP shortage over the next quartercentury under the best-case scenarioWe found that the best-case scenariofor the current system will beincapable of satisfying the growingdemand for PNPs Sensitivity analysisof our model revealed 3 policyinterventions to reduce PNPshortages and the expected numberof years required until the system isself-sufficient increases in PNPspecialization rates increases in PNPcertification examination passingrates and increases in the potentialannual growth rate of enrollmentsizes for PNP masterrsquos programsWithout policy interventions such asthose analyzed in this article the PNPshortage is expected to remain for thenext 13 years in the best-casescenario However by improving thePNP education and workforce systemthis forecasted shortage can bereduced to 5 years Given theimportant role of PNPs in the primaryand subspecialty care of pediatricpatients a reduction in the shortageof PNPs can improve access topediatric care for the growingpediatric population with complexand chronic diseases

ACKNOWLEDGMENTS

We thank MCubed for funding thisjoint project between engineering andmedicine We also thank thereviewers for their valuable feedbackon the manuscript And last we thankthe Pediatric Nursing CertificationBoard for providing the necessarydata for this research

REFERENCES

1 Freed GL Dunham KM Loveland-CherryCJ Martyn KK Research AdvisoryCommittee of the American Board ofPediatrics Pediatric nurse practitionersin the United States current distributionand recent trends in training J Pediatr2010157(4)589ndash593 e1

2 Shugerman RP Rimsza ME Basco WTet al Committee on Pediatric WorkforceScope of practice issues in the deliveryof pediatric health care Pediatrics 2013131(6)1211ndash1216

3 Freed GL Dunham KM Loveland-CherryC Martyn KK Moote MJ American Boardof Pediatrics Research AdvisoryCommittee Nurse practitioners andphysician assistants employed bygeneral and subspecialty pediatriciansPediatrics 2011128(4)665ndash672

4 Freed GL Dunham KM Loveland-CherryC Martyn KK American Board ofPediatrics Research Advisory CommitteeFamily nurse practitioners roles andscope of practice in the care of pediatricpatients Pediatrics 2010126(5)861ndash864

5 Basco WT Rimsza ME Committee onPediatric Workforce American Academyof Pediatrics Pediatrician workforcepolicy statement Pediatrics 2013132(2)390ndash397

6 National Research Council Institute ofMedicine Childrenrsquos health the nationrsquoswealth assessing and improving childhealth 2004 Available at wwwncbinlmnihgovbooksNBK92206 AccessedFebruary 1 2014

7 McClimon PJ Hansen TN Why arechildrenrsquos hospitals so busy J Pediatr2003142(3)219ndash220

8 Tough SC Newburn-Cook C Johnston DWSvenson LW Rose S Belik J Delayedchildbearing and its impact onpopulation rate changes in lower birthweight multiple birth and pretermdelivery Pediatrics 2002109(3)399ndash403

9 Freed GL Dunham KM Gebremariam AWheeler JRC Research AdvisoryCommittee of the American Board ofPediatrics Which pediatricians areproviding care to Americarsquos children Anupdate on the trends and changesduring the past 26 years J Pediatr 2010157(1)148ndash152 e1

10 Wall S Scudamore D Chin J et al Theevolving role of the pediatric nursepractitioner in hospital medicine J HospMed 20149(4)261ndash265

11 Jackson PL Kennedy C Sadler LS et alProfessional practice of pediatric nursepractitioners implications for educationand training of PNPs J Pediatr HealthCare 200115(6)291ndash298

12 Institute of Medicine The future ofnursing leading change advancinghealth 2011 Available at wwwnapeducatalogphprecord_id=12956 AccessedFebruary 1 2014

13 Thibault GE Reforming healthprofessions education will requireculture change and closer ties betweenclassroom and practice Health Aff(Millwood) 201332(11)1928ndash1932

14 Iglehart JK A new day dawns forworkforce redesign Health Aff(Millwood) 201332(11)1870

15 Dall TM Gallo PD Chakrabarti R West TSemilla AP Storm MV An agingpopulation and growing disease burdenwill require a large and specializedhealth care workforce by 2025 Health Aff(Millwood) 201332(11)2013ndash2020

16 Auerbach DI Will the NP workforce growin the future New forecasts andimplications for healthcare delivery MedCare 201250(7)606ndash610

17 Buerhaus PI Auerbach DI Staiger DOThe recent surge in nurse employmentcauses and implications Health Aff(Millwood) 200928(4)w657ndashw668

18 Fang D Li T Arietti R Bednash GDEnrollment and Graduations inBaccalaureate and Graduate Programsin Nursing 2013-2014 Washington DCAmerican Association of Colleges ofNursing 2014

19 Pediatric Nursing Certification BoardCertified pediatric nurse practitionerdata 2011-2013 Gaithersburgh MD

20 US Department of Human Services Theregistered nurse population initialfindings from the 2008 National Sample

PEDIATRICS Volume 135 number 2 February 2015 305 by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

Survey of Registered Nurses 2010Available at wwwuiowaedusimibldocumentsinitialfindings2008pdfAccessed February 1 2014

21 National Council of State Board ofNursing Number of candidates takingNCLEX examination and percent passingby type of candidate 2013 Available athttpswwwncsbnorgTable_of_Pass_Rates_2013pdf Accessed February 12014

22 Pediatric Nursing Certification BoardPassing rates 2013 Available at wwwpncborgptistorecontrolaboutabout_exams Accessed February 1 2014

23 American Associated of Colleges ofNursing Nursing shortage fact sheet2012 Available at wwwaacnncheedumedia-relationsfact-sheetsnursing-shortage Accessed February 1 2014

24 National Association of Pediatric NursePractitioners NAPNAP state map RN NPpopulations 2013 Available at wwwnapnaporgsitesdefaultfilesuserfilesaboutNAPNAP20201320State20Map

20RN20NP20PopulationspdfAccessed February 1 2014

25 Bureau of Labor Statistics Occupationalemployment statistics employment andwages 2011 Available at wwwblsgovoesoes_dlhtm Accessed February 12014

26 National Association of Pediatric NursePractitioners NAPNAP state map RN NPpopulations 2009 Available at wwwnapnaporg Accessed February 1 2014

27 Bertsimas D Tsitsiklis JN Introduction toLinear Optimization Belmont MA AthenaScientific 1997

28 Lavieri MS Puterman ML Optimizingnursing human resource planning inBritish Columbia Health Care ManageSci 200912(2)119ndash128

29 Freed GL Dunham KM Martyn KM et alPediatric nurse practitioners influenceson career choice J Pediatr Health Care2013

30 Leonard BJ Fulkerson JA Rose D ChristyA Pediatric nurse educator shortage

implications for the nursing care ofchildren J Prof Nurs 200824(3)184ndash191

31 American Association of NursePractitioners Nurse practitioners inprimary care 2013 Available at wwwaanporgimagesdocumentspublicationsprimarycarepdf Accessed February 1 2014

32 American Nurses Association Fundingfor nursing workforce development2013 Available at httpnursingworldorgDocumentVaultGOVAFederalFederal-IssuesNursingWorkforceDevelopmenthtmlAccessed February 1 2014

33 Freed GL Dunham KM Lamarand KELoveland-Cherry C Martyn KK AmericanBoard of Pediatrics Research AdvisoryCommittee Pediatric nursepractitioners roles and scope ofpractice Pediatrics 2010126(5)846ndash850

34 Moote M Krsek C Kleinpell R Todd BPhysician assistant and nursepractitioner utilization in academicmedical centers Am J Med Qual 201126(6)452ndash460

306 SCHELL et al by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2014-0967 originally published online January 26 2015 2015135298Pediatrics

and Gary L FreedGreggory J Schell Mariel S Lavieri Xiang Li Alejandro Toriello Kristy K Martyn

Strategic Modeling of the Pediatric Nurse Practitioner Workforce

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1352298including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1352298BIBLThis article cites 20 articles 9 of which you can access for free at

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by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2014-0967 originally published online January 26 2015 2015135298Pediatrics

and Gary L FreedGreggory J Schell Mariel S Lavieri Xiang Li Alejandro Toriello Kristy K Martyn

Strategic Modeling of the Pediatric Nurse Practitioner Workforce

httppediatricsaappublicationsorgcontent1352298located on the World Wide Web at

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ISSN 1073-0397 60007 Copyright copy 2015 by the American Academy of Pediatrics All rights reserved Print the American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village Illinoishas been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on January 21 2020wwwaappublicationsorgnewsDownloaded from